Evaluation of the chemical, antinutritional and antioxidant properties of composite flour comprising native and modified acha (digitaria exilis stapf) flour supplemented with mango kernel seed and soy cake flours.

Gluten-free flours that are nutritionally balanced with appropriate functional characteristics were developed by supplementation of native and modified acha flours with protein, dietary fiber and antioxidants-rich mango kernel and soy cakes flours. Acha flour was subjected to chemical and enzymatic modifications. The proximate, mineral compositions, bioactive and antinutrients properties of the composite flours were evaluated. The water content of the composite flours with native and chemically modified acha flour was between 7.62 and 9.30%, while that of enzymatic acha flour was between 10.12 and 10.79%. However, samples made with 20 and 30% incorporated mango kernel flour had around 13 and 19% increase in the protein content respectively, others including sample with enzymatically modified acha flour had lower protein content. On the other hand, all samples with enzymatically modified acha flour had between 83 and 100% increase in fibre content. The Na/K ratio of all the samples were less than one, as nutritionally required. Samples with enzymatically modified acha flour had best total flavonoid (0.03-0.77 mgGAE/g), total phenol (2.35-11.99 mgTAE/g) and DPPH radical scavenging activities (58.29-94.02%) contents. In addition, samples with enzymatically modified acha flour had the least antinutritional values. Although all the samples had values that were significantly (p ≥ 0.05) different, the samples had significant protein, dietary fiber, minerals and antioxidants contents, while the antinutritional contents were well lower than the standard.

The development of the American College Health Association-National College Health Assessment III: An improved tool to assess and enhance the health and well-being of college students.

This article describes the development of the American College Health Association-National College Health Assessment III (ACHA-NCHA III), a widely used comprehensive survey that assesses college students' health behaviors and outcomes at the institutional and national levels. Only the second major revision since the ACHA-NCHA was established in 2000, the ACHA-NCHA III launched in Fall of 2019. Background on the purpose and history of the ACHA-NCHA will first be provided. Then the systematic steps taken to create a new and enhanced version of the survey will be recounted. An overview of the final ACHA-NCHA III instrument will be given, and future directions for the survey post-implementation will be discussed.

Effect of biscuits formulated from acha-sandpaper leaf composite flour on fasting blood glucose, blood pressure, and activities of key enzymes linked to diabetes and hypertension in streptozotocin/l-NAME-induced hypertensive-diabetic rats.

Acha grains and sandpaper leaf are commonly used by locals for diabetes and hypertension management, respectively. However, this study sought to produce biscuits from acha-sandpaper leaf composite flour and evaluate their ameliorative potentials in streptozotocin (STZ)/Nω-nitro-l-arginine methylester hydrochloride (l-NAME)-induced hypertensive-diabetic rats. Group I (non-diabetic/normotensive), group II (negative control), group III (positive control) rats were placed on standard drugs, and groups IV-VII rats were placed on formulated biscuits supplemented with 0%, 1.25%, 2.5%, and 3.75% sandpaper leaf flour. The fasting blood glucose (FBG) and blood pressure (BP) of the experimental rats were measured. In addition, the activities of α-amylase, α-glucosidase, and angiotensin-1-converting enzyme (ACE) as well as antioxidant status were evaluated in all the groups and compared. However, the obtained results showed a significant reduction in the FBG and BP and in the activity of α-amylase, α-glucosidase, and ACE in biscuit-fed hypertensive-diabetes rats when compared with group II rats. Meanwhile, antioxidant status in biscuit-fed hypertensive-diabetes rats was enhanced when compared with the untreated hypertensive-diabetic rats. Nevertheless, biscuit with 3.75% sandpaper leaf had better hypertensive-diabetic property than other biscuits which could be linked to bioactive compounds present in the biscuits. PRACTICAL APPLICATIONS: Acha and sandpaper leaf has been used for the management of diabetes and hypertension respectively. However, formulating medicinal biscuits as a diary approach for the management of diabetic and its complication (hypertension) in STZ/l-NAME-induced hypertensive-diabetic rats is highly imperative. Based on our findings, cookies from the acha and sandpaper leaf flour blend exhibits pharmacological effect which could be linked to the presence of numerous bioactive constituents present in the cookies. Thus, the formulated cookies stand as a promising candidate for functional food and further work in this area is needed.

Management of a ruptured intraventricular aneurysm arising from distal anterior choroidal artery (AChA): pediatric case report.

Intracranial aneurysms arising from the distal anterior choroidal artery (AChA) are uncommon entities, with less than 30 cases reported. A 4-year-old boy was admitted to the Emergency Department with a sudden onset of severe headache and vomiting. CT scan of the head showed signs of intraventricular hemorrhage (IVH) and subarachnoid hemorrhage (SAH). Cerebral angiography revealed a right AChA aneurysm arising from a distal intraventricular branch with an associated microarteriovenous malformation (microAVM). Following a multidisciplinary assessment, the patient underwent surgical clipping. An ipsilateral transcortical transparietal approach was utilized. Early postoperative deficits were not found, and good clinical and radiological outcomes were assessed at long-term follow-up. Postoperative cerebral angiography showed complete exclusion and resection of both aneurysm and AVM. Surgery for intracranial aneurysms in this location can be challenging; however, good surgical and neurological outcomes can be achieved. The present work highlights the value of multidisciplinary assessment in the decision-making process in complex pediatric neurovascular pathology, especially when facing rare cases like this one, which represents the youngest case of a ruptured distal AChA aneurysm reported in the literature.

Consumer acceptability of acha and malted Bambara groundnut (BGN) biscuits sweetened with date palm.

Biscuits are ready to eat and convenient food product consumed among all age groups in most countries. The objective is to evaluate utilisation of acha, malted BGN and date palm flour in gluten-free, sugar-free biscuits. Mixture design was used to establish the appropriate proportion of acha, malted BGN and date palm flours for consumer acceptable biscuit. The sensory, physical, proximate and microbial properties of the biscuits were determined. The linear mixture model for taste, flavor and overall acceptability significantly (p < 0.05) explained the effect of the components on the sensory quality of the biscuits with strong correlation coefficient ranging from 0.574 for flavor to 0.944 for taste. The adequate precision was greater than 4 and the lack of fit was not significant. Hence, the linear mixture model could be used to navigate the space. Significant differences (p ≤ 0.05) existed in color, taste, flavor, texture, crispiness and overall acceptability of the biscuits. The biscuit produced with 60:10:30 acha, malted BGN and date palm, respectively was most preferred with a mean of 7.3. There was no significant difference between the preferred biscuit and the control 60:10:30 acha, malted BGN and sugar, respectively in colour, taste, flavour, texture except in crispiness. The physical properties for the most preferred biscuit are weight 23.0 g, height 3.0 g, spread ratio 7.7 and break strength 750 g with fat 20.1%, protein 11.9%, ash 2.6%, moisture 1.2%, crude fibre 4.3% and carbohydrate 60.0%. The microbial count for the most acceptable sample ranged from 1.0 x 10 3 to 4.0 x 10 3 cfu/g for bacteria and 1.0 x 10 4 to 5.0 x 10 4 cfu/g for mold/yeast. Hence, acha, malted BGN and date palm flours could produce consumer acceptable gluten-free, sugar-free biscuits.

Fonio grains: Physicochemical properties, nutritional potential, and food applications.

Fonio grains are a type of small-seeded cereals native to Western Africa and are important cereal crops for food security. The two species are white fonio (Digitaria exilis) (commonly called acha) and black fonio (Digitaria iburua) (commonly called iburu). As a novel food, fonio has attracted attention from other parts of the world due to their attractive nutritional properties (e.g., in whole grain form and being gluten free) and potential food applications. The information regarding the functional properties and applications of fonio is rather scattered. This review summarizes the chemical composition, physicochemical and nutritional properties, and diverse food applications of fonio. The nutritional composition and processing properties of fonio are similar to other cereals. Fonio has potential to be complementary to major cereals for diverse food uses. There are research opportunities to better explore fonio grains for value-added applications.

The second fifty years: A history of the American College Health Association.

Objective: On the occasion of the American College Health Association's (ACHA) 100th anniversary, this article seeks to explore the second fifty years of its organizational history, as well as many of the key historical moments in the field of American college health. Materials and methods: This article examines ACHA's second fifty years, decade-by-decade, in key thematic areas that have driven focus, innovation and change at both ACHA and the field of college health and well-being, including: Changes in ACHA Governance, Leadership and Organizational Structure; Clinical Care, Immunizations, Emergency Preparedness and Outbreak Response; Health Promotion: Moving from Health to Wellness to WellBeing; Mental Health: Stigma, Suicide and Access to Care; Nursing Practice and Nurse Certification; Using Education, Research, Data and Publications to Drive Change and Innovation; Advocacy for the Health of College Students and Our College Communities; Growth and Development of the American College Health Foundation; and Recognizing Quality of Care, Excellence and Outstanding Contributions to ACHA. Results: ACHA's second fifty years have provided an enormous volume of high-quality programs and services, used to further improve the health and well-being of college students. The narrative shows that the organization has indeed met its mission over the past fifty years. The article concludes with predictions of changes and advances at ACHA in the next decade. Conclusions: Since 1920, ACHA has served as the voice for college student health and well-being in the United States. ACHA's second fifty years is a remarkable story of hard work, vision and achievement by a large number of talented and committed college health professionals, students and colleagues across college campuses and in sister professional organizations.

Clipping on Crossed Wrapping Method for Ruptured Blood Blister-Like Aneurysm of the Internal Carotid Artery: Technical Note and Long-Term Results.

BACKGROUND: We have been performing the clipping on crossed wrapping (COCW) method using 2 strips of cotton on patients with an internal carotid artery blood blister-like aneurysm (IC-BLA). This method is reliable in preventing the clips from slipping off and the aneurysm walls from being damaged during clipping, and it enables more appropriate and safer clipping. Here we report the technical details of this method and the long-term outcomes of patients receiving this procedure. METHODS: Fifteen of 1275 (1.5%) patients with a ruptured cerebral aneurysm who received treatment at the Saiseikai Kumamoto Hospital during the period from January 1, 1999, to December 31, 2016, had an IC-BLA. All 15 patients were treated with COCW, except for the first patient, who was treated using a single strip of cotton. The long-term outcome of the treatment was analyzed. RESULTS: The mean follow-up period was 74 months. The first patient experienced rerupture of an aneurysm 10 days after the operation. No complications or regrowth of an aneurysm were observed in the remaining 14 patients during the follow-up period, except for 1 patient who received a reoperation for the regrowth of an aneurysm. As the final outcome, the numbers of patients with a Modified Rankin Score of 0, 3, and 6 were 13, 1, and 1, respectively. CONCLUSIONS: It is suggested that COCW is a treatment that enables safe and long-term management of lesions in IC-BLAs.

FRED Italian Registry: a multicenter experience with the flow re-direction endoluminal device for intracranial aneurysms.

OBJECTIVE: The introduction of flow-diverter devices (FDDs) has revolutionized the endovascular treatment of intracranial aneurysms. Here the authors present their Italian multicenter experience using the flow re-direction endoluminal device (FRED) in the treatment of cerebral aneurysms, evaluating both short- and long-term safety and efficacy of this device. METHODS: Between February 2013 and December 2014, 169 consecutive aneurysms treated using FRED in 166 patients were entered into this study across 30 Italian centers. Data collected included patient demographics, aneurysm location and characteristics, baseline angiography, adverse event and serious adverse event information, morbidity and mortality rates, and pre- and posttreatment modified Rankin Scale scores, as well as angiographic and cross-sectional CT/MRI follow-up at 3-6 months and/or 12-24 months per institutional standard of care. All images were reviewed and adjudicated by an independent core lab. RESULTS: Of the 169 lesions initially entered into the study, 4 were later determined to be extracranial or nonaneurysmal by the core lab and were excluded, leaving 165 aneurysms in 162 patients treated in 163 procedures. Ninety-one (56.2%) patients were asymptomatic with aneurysms found incidentally. Of the 165 aneurysms, 150 (90.9%) were unruptured. One hundred thirty-four (81.2%) were saccular, 27 (16.4%) were fusiform/dissecting, and the remaining 4 (2.4%) were blister-like. One hundred thirty-seven (83.0%) arose from the anterior circulation.FRED deployment was impossible in 2/163 (1.2%) cases, and in an additional 4 cases (2.5%) the device was misdeployed. Overall mortality and morbidity rates were 4.3% and 7.3%, respectively, with rates of mortality and morbidity potentially related to FRED of up to 2.4% and 6.2%, respectively. Neuroimaging follow-up at 3-6 months showed complete or nearly complete occlusion of the aneurysm in 94% of cases, increasing to 96% at 12-24 months' follow-up. Aneurysmal sac shrinkage was observed in 78% of assessable aneurysms. CONCLUSIONS: This preliminary experience using FRED for endovascular treatment of complex unruptured and ruptured aneurysms showed a high safety and efficacy profile that is comparable to those of other FDDs currently in use.

Using Classification Trees to Examine Predictors of Marijuana Use Among a Wide Range of Variables.

Background: Young adults have elevated risk for negative marijuana use-related outcomes, and there is heterogeneity among users. Identifying risk factors for marijuana user status will improve understanding of different populations of users, which may inform prediction of individuals most likely to experience negative outcomes. Objectives: To identify predictors of marijuana use initiation in young adults. We simultaneously examined a broad range of potential predictors and all their possible interactions, including constructs that have not been previously studied in substance use initiation research. Methods: Data were repeated cross-sectional survey responses from college students in Colorado (N = 4052, 77% White, 61% female, mean age = 22.77). Measures came from the National College Health Assessment, which assesses numerous health and behavioral constructs. We used recursive partitioning and random forest models to identify predictors of ever having used marijuana out of 206 variables. Results: Classification trees identified engagement in increased alcohol use and sexual behavior as salient correlates of marijuana use initiation. Parsimonious recursive partitioning trees explained a substantial amount of variability in marijuana user status (39% in the full model and 24% when alcohol variables were excluded). Random forest models predicted user status with 74.11% and 66.91% accuracy in the full model and when alcohol variables were excluded, respectively. Conclusions: Results support the use of exploratory analyses to explain heterogeneity among marijuana users and non-users. Since engagement in other health-risk behaviors were salient predictors of use initiation, prevention efforts to reduce harm from marijuana use may benefit from targeting risk factors for health-risk behaviors in general.

Incidence, classification, and treatment of angiographically occult intracranial aneurysms found during microsurgical aneurysm clipping of known aneurysms.

OBJECTIVE: During the microsurgical clipping of known aneurysms, angiographically occult (AO) aneurysms are sometimes found and treated simultaneously to prevent their growth and protect the patient from future rupture or reoperation. The authors analyzed the incidence, treatment, and outcomes associated with AO aneurysms to determine whether limited surgical exploration around the known aneurysm was safe and justified given the known limitations of diagnostic angiography. METHODS: An AO aneurysm was defined as a saccular aneurysm detected using the operative microscope during dissection of a known aneurysm, and not detected on preoperative catheter angiography. A prospective database was retrospectively reviewed to identify patients with AO aneurysms treated microsurgically over a 20-year period. RESULTS: One hundred fifteen AO aneurysms (4.0%) were identified during 2867 distinct craniotomies for aneurysm clipping. The most common locations for AO aneurysms were the middle cerebral artery (60 aneurysms, 54.1%) and the anterior cerebral artery (20 aneurysms, 18.0%). Fifty-six AO aneurysms (50.5%) were located on the same artery as the known saccular aneurysm. Most AO aneurysms (95.5%) were clipped and there was no attributed morbidity. The most common causes of failed angiographic detection were superimposition of a large aneurysm (type 1, 30.6%), a small aneurysm (type 2, 18.9%), or an adjacent normal artery (type 3, 36.9%). Multivariate analysis identified multiple known aneurysms (odds ratio [OR] 3.45, 95% confidence interval [CI] 2.16-5.49, p < 0.0001) and young age (OR 0.981, 95% CI 0.965-0.997, p = 0.0226) as independent predictors of AO aneurysms. CONCLUSIONS: Meticulous inspection of common aneurysm sites within the surgical field will identify AO aneurysms during microsurgical dissection of another known aneurysm. Simultaneous identification and treatment of these additional undiagnosed aneurysms can spare patients later rupture or reoperation, particularly in those with multiple known aneurysms and a history of subarachnoid hemorrhage. Limited microsurgical exploration around a known aneurysm can be performed safely without additional morbidity.

Outcomes after coverage of lenticulostriate vessels by flow diverters: a multicenter experience.

OBJECTIVE: With the increasing use of flow diversion as treatment for intracranial aneurysms, there is a concomitant increased vigilance in monitoring complications. The low porosity of flow diverters is concerning when the origins of vessels are covered, whether large circle of Willis branches or critical perforators. In this study, the authors report their experience with flow diverter coverage of the lenticulostriate vessels and evaluate their safety and outcomes. METHODS: The authors retrospectively reviewed 5 institutional databases of all flow diversion cases from August 2012 to June 2018. Information regarding patient presentation, aneurysm location, treatment, and outcomes were recorded. Patients who were treated with flow diverters placed in the proximal middle cerebral artery (MCA), proximal anterior cerebral artery, or distal internal carotid artery leading to coverage of the medial and lateral lenticulostriate vessels were included. Clinical outcomes according to the modified Rankin Scale were reviewed. Univariate and multivariate analyses were performed to establish risk factors for lenticulostriate infarct. RESULTS: Fifty-two patients were included in the analysis. Postprocedure cross-sectional images were available in 30 patients. Two patients experienced transient occlusion of the MCA during the procedure; one was asymptomatic, and the other had a clinical and radiographic ipsilateral internal capsule stroke. Five patients had transient symptoms without radiographic infarct in the lenticulostriate territory. Two patients experienced in-stent thrombosis, leading to clinical MCA infarcts (one in the ipsilateral caudate) after discontinuing antiplatelet therapy. Discontinuation of dual antiplatelet therapy prior to 6 months was the only variable that was significantly correlated with stroke outcome (p < 0.01, OR 0.3, 95% CI 0-0.43), and this significance persisted when controlled for other risk factors, including age, smoking status, and aneurysm location. CONCLUSIONS: The use and versatility of flow diversion is increasing, and safety data are continuing to accumulate. Here, the authors provide early data on the safety of covering lenticulostriate vessels with flow diverters. The authors concluded that the coverage of these perforators does not routinely lead to clinically significant ischemia when dual antiplatelet therapy is continued for 6 months. Further evaluation is needed in larger cohorts and with imaging follow-up as experience develops in using these devices in more distal circulation.

Encephaloduroarteriosynangiosis for hemorrhagic moyamoya disease: long-term outcome of a consecutive series of 95 adult patients from a single center.

OBJECTIVE: The objective of this study was to investigate long-term outcomes after encephaloduroarteriosynangiosis (EDAS) for the treatment of hemorrhagic moyamoya disease (MMD) and identify the risk factors for recurrent hemorrhages. METHODS: The authors retrospectively reviewed 95 patients with hemorrhagic MMD who were treated with EDAS at 307th Hospital PLA. Clinical features, angiographic findings, and clinical outcomes were investigated. Rebleeding incidences were compared between anterior or posterior hemorrhagic sites. Kaplan-Meier survival analysis and Cox proportional hazards regression models were used to estimate rebleeding risks after EDAS. RESULTS: The average age at symptom onset was 37.1 years (range 20-54 years) for adult patients. The ratio of female to male patients was 1.16:1. In 61 of 95 hemorrhagic hemispheres (64.2%), the anterior choroidal artery (AChA) or posterior communicating artery (PCoA) was extremely dilated, with extensive branches beyond the choroidal fissure, which only occurred in 28 of 86 nonhemorrhagic hemispheres (32.6%). Fifty-seven incidences were classified as anterior hemorrhages and 38 as posterior. Sixteen of 95 patients (16.8%) suffered cerebral rebleeding after a median follow-up duration of 8.5 years. The annual rebleeding rate was 2.2% per person per year. The incidence rate was higher for the posterior group than for the anterior group, but this difference was not statistically significant (p > 0.05). Cox regression analysis revealed that the age of symptom onset (OR 1.075, 95% CI 1.008-1.147, p = 0.028) was a predictor of rebleeding strokes. CONCLUSIONS: Through long-term follow up, EDAS proved beneficial for patients with hemorrhagic MMD. Dilation of the AChA-PCoA is associated with the initial hemorrhage of MMD, and rebleeding is age-related. Patients with hemorrhagic MMD should undergo follow-up over the course of their lives, even when neurological status is excellent.

Ischemic stroke following elective craniotomy in children.

OBJECTIVE An ischemic stroke following an elective craniotomy in a child is perceived to be a rare event. However, to date there are few papers on this topic. The purpose of this study was to investigate the occurrence of stroke following elective intracranial surgery at a children's hospital. METHODS The authors performed a retrospective review of all patients who developed a perioperative stroke following an elective craniotomy from 2010 through 2017. Data were collected using an institutional database that contained demographic, medical, radiological, and outcome variables. RESULTS A total of 1591 elective craniotomies were performed at the authors' institution during the study period. Of these, 28 (1.8%) were followed by a perioperative stroke. Radiographic diagnosis of the infarction occurred at a median of 1.7 days (range 0­9 days) from the time of surgery, and neurological deficits were apparent within 24 hours of surgery in 18 patients (62.5%). Infarcts tended to occur adjacent to tumor resection sites (86% of cases), and in a unilateral (89%), unifocal (93%), and supratentorial (93%) location. Overall, 11 (39.3%) strokes were due to a perforating artery, 10 (35.7%) were due to a large vessel, 4 (14.3%) were venous, and 3 (10.7%) were related to hypoperfusion or embolic causes. Intraoperative MRI (iMRI) was used in 11 of the 28 cases, and 6 (55%) infarcts were not detected, all of which were deep. CONCLUSIONS The incidence of stroke following an elective craniotomy is low, with nearly all cases (86%) occurring after tumor resection. Perforator infarcts were most common but may be missed on iMRI. ABBREVIATIONS ACA = anterior cerebral artery; AChA = anterior choroidal artery; ACS NSQIP-P = American College of Surgeons National Surgical Quality Improvement Program­Pediatric; CVA = cerebrovascular accident; DWI = diffusion weighted imaging; iMRI = intraoperative MRI; MCA = middle cerebral artery; mRS = modified Rankin Scale; PCA = posterior cerebral artery.

Development of value-added nutritious crackers with high antidiabetic properties from blends of Acha (Digitaria exilis) and blanched Pigeon pea (Cajanus cajan).

Pigeon pea was treated by blanching and used to supplement acha flour for the development of functional cracker biscuits. The flour ratios for acha and pigeon pea were 100:0 (ACC), 80:20 (APC1), and 70:30 (APC2), respectively. The developed cracker biscuits were evaluated for chemical acid compositions, antioxidant, as well as antidiabetic properties. Protein contents of the formulated crackers increased with increase in supplementation with pigeon pea flour. The antinutrient content of the formulated snack was low hence may not adversely affect nutrient bioavailability. Glutamic and aspartic acids were the predominant amino acids while methionine and lysine significantly increased as a result of supplementation with pigeon pea flour. The biscuit exhibited good antioxidant properties indicated by its strong ability to scavenge hydroxyl, superoxide, DPPH radicals, and reduced Fe3+ to Fe2+. The formulated snack especially APC2 possessed low glycemic index (47.95%) and significantly inhibited the key digestive enzymes (α-amylase and α-glucosidase). All parameters evaluated indicated that APC2 could serve as a functional snack in the management of hyperglycemia (diabetes) and prevention of associated degenerative diseases.

Evaluating Variability in Immunization Requirements and Policy Among U.S. Colleges and Universities.

OBJECTIVES: To evaluate variation in vaccine requirements, recommendations, and enforcement strategies among U.S. four-year colleges and universities. METHODS: We conducted a cross-sectional study abstracting information from Web sites among a sample of 216 four-year colleges and universities from all 50 states and District of Columbia. Our primary outcomes of interest included: type and number of vaccines required for school entry, vaccines recommended by schools for students, and vaccines supplied through student health services. Covariates of interest included: school type, region, school size, mention of American College Health Association recommendations, presence of an accredited health center, mention of state requirements, presence of an enforcement strategy, and exemption stringency of the state in which the school was located. RESULTS: Almost all (94%) schools required at least one vaccine for school entry, and 48% required three or more vaccines. The most commonly required vaccines were measles, mumps, and rubella (88.4%) and meningococcal vaccine (51.9%). All schools required the same vaccines included in state requirements but 65% also required additional vaccines. Most schools (67.1%) used registration hold to enforce requirements, while 14.8% restricted students from campus housing and 2.8% dismissed noncompliant students. Seventeen percent of schools had no published enforcement strategies. A higher proportion of private compared to public universities required three or more vaccines (57% vs. 37.3%, p = .014). CONCLUSIONS: While most schools have immunization requirements, there is significant variation in number and type of vaccines required. This suggests potential inconsistent uptake of recommended vaccines for college students and underlies the need to characterize facilitators and barriers to immunization program implementation on college campuses.

The oculomotor-tentorial triangle. Part 1: microsurgical anatomy and techniques to enhance exposure.

OBJECTIVEAccess to the ventrolateral pontomesencephalic area may be required for resecting cavernous malformations, performing revascularization of the upper posterior circulation, and treating vascular lesions such as aneurysms. However, such access is challenging because of nearby eloquent structures. Commonly used corridors to this surgical area include the optico-carotid, supracarotid, and carotid-oculomotor triangles. However, the window lateral to the oculomotor nerve can also be used and has not been studied. The authors describe the anatomical window formed between the oculomotor nerve and the medial tentorial edge (the oculomotor-tentorial triangle [OTT]) to the ventrolateral pontomesencephalic area, and assess techniques to expand it.METHODSFour cadaveric heads (8 sides) underwent orbitozygomatic craniotomy. The OTT was exposed via a pretemporal approach. The contents of the OTT were determined and their anatomical features were recorded. Also, dimensions of the brainstem surface exposed lateral and inferior to the oculomotor nerve were measured. Measurements were repeated after completing a transcavernous approach (TcA), and after resection of temporal lobe uncus (UnR).RESULTSThe s1 segment and proximal s2 segment of the superior cerebellar artery (SCA) and P2A segment of the posterior cerebral artery (PCA) were the main contents of the OTT, with average exposed lengths of 6.4 ± 1.3 mm and 5.5 ± 1.6 mm for the SCA and PCA, respectively. The exposed length of the SCA increased to 9.6 ± 2.7 mm after TcA (p = 0.002), and reached 11.6 ± 2.4 mm following UnR (p = 0.004). The exposed PCA length increased to 6.2 ± 1.6 mm after TcA (p = 0.04), and reached 10.4 ± 1.8 mm following UnR (p < 0.001). The brainstem surface was exposed 7.1 ± 0.5 mm inferior and 5.6 ± 0.9 mm lateral to the oculomotor nerve initially. The exposure inferior to the oculomotor nerve increased to 9.3 ± 1.7 mm after TcA (p = 0.003), and to 9.9 ± 2.5 mm after UnR (p = 0.21). The exposure lateral to the oculomotor nerve increased to 8.0 ± 1.7 mm after TcA (p = 0.001), and to 10.4 ± 2.4 mm after UnR (p = 0.002).CONCLUSIONSThe OTT is an anatomical window that provides generous access to the upper ventrolateral pontomesencephalic area, s1- and s2-SCA, and P2A-PCA. This window may be efficiently used to address various pathologies in the region and is considerably expandable by TcA and/or UnR.

The oculomotor-tentorial triangle. Part 2: a microsurgical workspace for vascular lesions in the crural and ambient cisterns.

OBJECTIVEPathology in the region of the basilar quadrifurcation, anterolateral midbrain, medial tentorium, and interpeduncular and ambient cisterns may be accessed anteriorly via an orbitozygomatic (OZ) craniotomy. In Part 1 of this series, the authors explored the anatomy of the oculomotor-tentorial triangle (OTT). In Part 2, the versatility of the OTT as a surgical workspace for treating vascular pathology is demonstrated.METHODSSixty patients with 61 vascular pathologies treated within or via the OTT from 1998 to 2017 by the senior author were retrospectively reviewed. Patients were grouped together based on pathology/surgical procedure and included 1) aneurysms (n = 19); 2) posterior cerebral artery (PCA)/superior cerebellar artery (SCA) bypasses (n = 24); 3) brainstem cavernous malformations (CMs; n = 14); and 4) tentorial region dural arteriovenous fistulas (dAVFs; n = 4). The majority of patients were approached via an OZ craniotomy, wide sylvian fissure split, and temporal lobe mobilization to widen the OTT.RESULTSAneurysm locations included the P1-P2 junction (n = 7), P2A segment (n = 9), P2/3 (n = 2), and basilar quadrification (n = 1). Aneurysm treatments included clip reconstruction (n = 12), wrapping (n = 3), proximal occlusion (n = 2), and trapping with (n = 1) or without (n = 1) bypass. Pathologies in the bypass group included vertebrobasilar insufficiency (VBI; n = 3) and aneurysms of the basilar trunk (n = 13), basilar apex (n = 4), P1 PCA (n = 2), and s1 SCA (n = 2). Bypasses included M2 middle cerebral artery (MCA)-radial artery graft (RAG)-P2 PCA (n = 8), M2 MCA-saphenous vein graft (SVG)-P2 PCA (n = 3), superficial temporal artery (STA)-P2 PCA (n = 5) or STA-s1 SCA (n = 3), s1 SCA-P2 PCA (n = 1), V3 vertebral artery (VA)-RAG-s1 SCA (n = 1), V3 VA-SVG-P2 PCA (n = 1), anterior temporal artery-s1 SCA (n = 1), and external carotid artery (ECA)-SVG-s1 SCA (n = 1). CMs were located in the midbrain (n = 10) or pontomesencephalic junction (n = 4). dAVFs drained into the tentorial, superior petrosal, cavernous, and sphenobasal sinuses. High rates of aneurysm occlusion (79%), bypass patency (100%), complete CM resection (86%), and dAVF obliteration (100%) were obtained. The overall rate of permanent oculomotor nerve palsy was 8.3%. The majority of patients in the aneurysm (94%), CM (93%), and dAVF (100%) groups had stable or improved modified Rankin Scale scores.CONCLUSIONSThe OTT is an important anatomical triangle and surgical workspace for vascular lesions in and around the crural and ambient cisterns. The OTT can be used to approach a wide variety of vascular pathologies in the region of the basilar quadrifurcation and anterolateral midbrain.

Occlusion rates of intracranial aneurysms treated with the Pipeline embolization device: the role of branches arising from the sac.

OBJECTIVEThe aim of this study was to compare the clinical and angiographic outcomes of intracranial aneurysms with and without branches arising from the sac after Pipeline embolization device (PED) treatment.METHODSThis retrospective 2-center comparative study included 116 patients with 157 aneurysms that were treated with PEDs. Aneurysms were divided into 2 groups: one group had branches arising from the sac and the other group did not. Study end points included total aneurysm occlusion assessed by angiography at 6 and 12 months, death or stroke, technical complications, in-stent stenosis, patency of covered branches, and transient ischemia.RESULTSOne hundred fifty-one aneurysms (96%) were located in the internal carotid artery. A branch arising from the sac was observed in 26 aneurysms. Complete occlusion was found in 120 of 156 aneurysms at 6 months (76.92% [95% CI 69.71%-82.84%]) and in 136 of 155 aneurysms at 12 months (87.74% [95% CI 81.28%-92.27%]). Total occlusion was more frequently observed in the group without a branch arising from the sac (84% vs 40% at 6 months, p < 0.001; 93.10% vs 60% at 1 year, p < 0.001). There were 4 (3.45% [95% CI 1.11%-9.12%]) cases of death or major stroke. Amaurosis fugax occurred in 3 patients. One patient experienced worsening of mass effect after treatment. No occlusion of branches arising from the aneurysm was observed. In-stent stenosis greater than 50% was observed in 1 case.CONCLUSIONSAneurysms treated with PEDs are less likely to be totally occluded if they have a branch arising from the sac than are aneurysms without these branches.

Intraoperative use of transcranial motor/sensory evoked potential monitoring in the clipping of intracranial aneurysms: evaluation of false-positive and false-negative cases.

OBJECTIVE: Somatosensory and motor evoked potentials (SEPs and MEPs) are often used to prevent ischemic complications during aneurysm surgeries. However, surgeons often encounter cases with suspicious false-positive and false-negative results from intraoperative evoked potential (EP) monitoring, but the incidence and possible causes for these results are not well established. The aim of this study was to investigate the efficacy and reliability of EP monitoring in the microsurgical treatment of intracranial aneurysms by evaluating false-positive and false-negative cases. METHODS: From January 2012 to April 2016, 1514 patients underwent surgery for unruptured intracranial aneurysms (UIAs) with EP monitoring at the authors' institution. An EP amplitude decrease of 50% or greater compared with the baseline amplitude was defined as a significant EP change. Correlations between immediate postoperative motor weakness and EP monitoring results were retrospectively reviewed. The authors calculated the sensitivity, specificity, and positive and negative predictive values of intraoperative MEP monitoring, as well as the incidence of false-positive and false-negative results. RESULTS: Eighteen (1.19%) of the 1514 patients had a symptomatic infarction, and 4 (0.26%) had a symptomatic hemorrhage. A total of 15 patients showed motor weakness, with the weakness detected on the immediate postoperative motor function test in 10 of these cases. Fifteen false-positive cases (0.99%) and 8 false-negative cases (0.53%) were reported. Therefore, MEP during UIA surgery resulted in a sensitivity of 0.10, specificity of 0.94, positive predictive value of 0.01, and negative predictive value of 0.99. CONCLUSIONS: Intraoperative EP monitoring has high specificity and negative predictive value. Both false-positive and false-negative findings were present. However, it is likely that a more meticulously designed protocol will make EP monitoring a better surrogate indicator of possible ischemic neurological deficits.